Diagnosis and Management of Unusual Oral Mucosal Diseases and Disorders in Periodontal

PracticeAmerican Academy of Periodontology

Philadelphia PennsylvaniaOctober 1, 2013

Terry D. Rees DDS, MSD

� Professor, Department of Periodontics

� Director, Stomatology CenterBaylor College of DentistryTexas A&M Health Science CenterDallas, Texas

Disclosure:

No Conflicts of Interest

Desquamative Gingivitis� A clinical manifestation of several diseases and disorders featuring gingival erythema,

sloughing of gingival epithelial tissues and potentially painful erosive gingival lesions.� Mostly caused by mucocutaneous diseases with the most common being lichen planus,

mucous membrane pemphigoid and pemphigus vulgaris. Other causes include hypersensitivity reactions to various oral hygiene products and dental materials.

� Confirmed diagnosis may require histopathological examination and direct immunofluorescence testing.

Characteristic Features

� Gingival erythema not resulting from plaque

� Desquamation and erosion of gingival epithelium

� Blister formation.

� Other intraoral and/or extraoral lesions

� Possible positive Nikolsky’s sign ( epithelial desquamation after application of a shearing force on normal-appearing gingiva.

Phases of Therapy

Diagnostic phase Control phaseConsolidation phaseMaintenance phaseModified from:

Brystryn, 1988Sciubba, 1996

Diagnostic Phase

� Past history

� Clinical appearance

� Biopsy

� Histology

� Direct immunofluorescence

� Indirect immunofluorescence

� Culture/smear

� Ancillary tools

� Brush biopsy

� Toulidine Blue

� Ultraviolent lighting

Tricks of the Trade

“Special skills and knowledge associated with any trade or profession”

McGraw-Hill Dictionary of American Idioms

Biopsy Site Selection

� Choose an area of intact epithelium

� Include perilesional tissue

� Select normal appearing tissue for some immunofluorescence testing

� When possible avoid gingival biopsies

Epithelium off

Conventional technique

Stab and Roll Technique

Stab Roll

PUNCH BIOPSY

POST-SURGICAL MANAGEMENT

� Hemostasis

� Pressure

� Monsel’s Solution (Ferric Subsulfate)

� Synthetic collagen

� Gelfoam

SHIPMENT

� Formaldehyde for Routine Histologic Evaluation

� Ambient Temperature Transport Media (Michelle’s Solution)

� for DIF

� Obtain from Pathology Lab or

Immunology Lab, Usually

without Charge

Control Phase

� Intense therapy to suppress disease in days or weeks

� Efficacy versus safety versus patient acceptance

� Avoid patient disenchantment over multiple daily treatment yet minimal results.

� Prevent side effects such as candidiasis.

Control Phase Alternatives

� Aggressive therapy with very high potency topical or systemic corticosteroids

� Moderate therapy with high potency topical corticosteroids combined with intralesional injections when indicated

� Mild therapy with medium or low potency topical corticosteroids and carrier (Kenalog in Orabase, denture adhesives, patches etc.)

High Potency Topical Corticosteroids

� 0.25% Desoximetasone (Topicort)

� 0.20% Fluocinolone (Synalar HP)

� 0.05% Fluocinonide (Lidex)

� 0.50% Triamcinolone Acetonide (Aristocort, Kenalog)

Monitor quantity used and do not exceed 15 grams within two weeks

Highest Potency Topical Corticosteroids

� Betamethasone dipropionate (Diprolene) 0.05% gel, cream, ointment

� Clobetasol (Temovate) 0.05% gel,cream, ointment

� Halobetasol (Ultravate) 0.05% cream, ointment

Steroid Carrier Trays

Disadvantages to Carrier Trays

� Insertion and removal may initiate gingival desquamation

� Risk of increased systemic uptake

� Risk of gingival epithelial thinning

Intralesional Corticosteroids� Deliver high concentration to diseased site with minimal systemic absorption

� Use alone or in combination with other therapy� Triamcinolone acetonide injectable (Kenalog 10mg/ml or 40 mg/ml)� Tuberculin syringe (27 gauge)� Inject 1mg/cm2

� Repeat at 1-2 week intervals if needed up to 4 times� Primarily use- buccal, labial mucosa, or tongue

Consolidation Phase

� Maintain required type and dose of medications until bulk of lesions have healed

� Weeks not months

� If lesions are slow to heal, choice of therapy or its intensity may be inadequate

Maintenance Phase

� Gradually taper frequency of medication use and/or potency of medication

� Goal is to achieve complete remission or minimize symptoms and to determine lowest dosage necessary to prevent new lesions

� Sustain periodontal health with frequent recall intervals, oral antimicrobials, etc.

� Determine appropriate recall intervals

Department of PeriodonticsStomatology Center

Baylor College of DentistrySeptember 12, 2013

Number of Patients: 8038

Disease Frequency8o38 Patients (BCD) (September 2013)

� Erosive lichen planus/ lichenoid drug reaction (1045) 13.0%� Xerostomia (845) 10.5%� Chronic candidiasis (794) 9.9% � Aphthae & other ulcerations (521) 6.5%� Sjögren’s syndrome (447) 5.6%� Allergic reactions (351) 4.4%� Burning mouth syndrome (328) 4.1%� Mucous membrane pemphigoid (228) 2.8%� Hyperkeratosis (184) 2.3%� Migratory glossitis (143) 1.8% � Oral malignancies (85) 1.1%� Pemphigus vulgaris (60) 0.8%_________________________________________________________________________________

TOTAL (5031) 62.8%

Other Disorders Causing Desquamative Gingivitis(BCD) (September 2013)

� Graft vs. host disease 33� Lupus erythematosus 16� Lichen planus/Pemphigoides 15� Erythema multiforme 14� Leukemic/lymphocytic gingivitis 9� Chronic ulcerative stomatitis 9� Scleroderma 11� Psoriasis 8

� Sarcoidosis 8 � Gingival histiocytosis X 4� Epidermolysis bullosa 4� Wegener's granulomatosis 3� Pyostomatitis vegetans 3� Actinomycosis 2� Gingival histoplasmosis 2� Ehlers-Danlos syndrome 2

Pemphigoid DiseasesA group of 7 autoimmune disorders characterized by autoimmunity directed toward

structural proteins of the basement membrane junction area.Schmitt E, Killikens D. Lancet 2013;381:320-332

� Bullous pemphigoid –Bp 180, 230

� Mucous membrane pemphigoid –BP 180, 230, type VII collagen

� Pemphigoid gestationis- Bp 180,230

� Linear IgA disease- LAD 1, Bp 230

� Epidermolysis bullosa acquisita- type VII collagen

� Anti-laminen pemphigoid- Laminen

� Lichen planus pemphigoides- Bp 180, 230

Bullous Pemphigoid

Mucous Membrane Pemphigoid

Dr. Terry Rees

Mucous Membrane Pemphigoid

� Autoimmune disorder� Oral &/or other mucous

membranes affected

� Mean age of onset = 50� Females > Males

MMP Clinical Sites (September 12, 2013)

Gingiva 89.5%Mucosa 24.4% Palate 10.5%

Tongue 7.2%Pharynx 1.1%

Dr. Terry Rees

MMP Diagnosis

� Clinical appearance� Histopathological examination

� Immunofluorescence

Dr. Terry Rees

MMP Laboratory Confirmation

� 155 patients

�DIF 90.6%

�Histopathology 78.7%

� 11 patients diagnosed by H&E alone

� 5 patients diagnosed by DIF alone

Ocular Pemphigoid

� After diagnosis of oral MMP refer for ophthalmology evaluation

Treatment

� Steroids similar to oral lichen planus

� Steroid carrier trays

� Plaque control

� Low dose doxycycline?

� Systemic:

� Dapsone

� Tetracycline/Nicotinamide

� Azathioprine

� Mycophenolate mofetil (CellCept)

� Cyclophosphamide

� Itravenous immunoglobulin (IVIG)

� Rituximab

Periodontal Status in Patients with Gingival MMP

� Markedly significant increase in plaque and gingival indices.

� Significant increases in class 1 molar furcation involvement and gingival recession

� Periodontal index not significantly increasedTricamo, Melissa et al

J. Periodontol 2006:77:398.

Periodontal status in patients with mucous membrane pemphigoid: a 5 year follow-up

� 10 of the same MMP and age, sex and smoking matched control patients compared 5 years later.

� MMP patients had higher gingival index and lingual gingival recession

� Both groups exhibited significant increases in attachment loss but no difference between groups

� Conclusion: MMP patients appear at no greater risk of increased progression of periodontal disease.

Schellinck AE et al. J Periodontol 2009;80:1765-1773.

Dr. Terri Rees

MMP Results of Treatment 102 Patients

Treatment Remission: Complete PartialTopical steroids only 15 44

Topical+short term systemic 12 10Topical+long term systemic 6 4

Topical+Dapsone 3 2 Topical+antibiotics 4 2

Total 41 (40.2%) 61)59.8%)

Therapy Issues

� It is not known whether asymptomatic lesions should be treated

� Therapeutic endpoints required to prevent progression have not been established

Pemphigus

One of a group of chronic relapsing autoimmune diseases that cause blisters and erosions of the skin and mucous membranes.

Types of Pemphigus

� Vulgaris- Generalized blisters and erosions.

� Vegetans- Bullae replaced by verrucous, hypertrophic vegetative masses.

� Erythematosus- Erythematous pustular lesions limited to face and trunk. Mainly on nose, periorbital skin and ear

� Foliaceus- Generalized scaling dermatitis with bullae.

Other forms of Pemphigus� Paraneoplastic- Painful mucosal erosions often resembling erythema multiforme. Eventually will affect skin. Associated with presence of a neoplasm.

� Benign familial (Hailey-Hailey Disease)-Rare hereditary condition causing recurrent eruptions of vesicles and bullae mainly on neck, axillae and groin. Unrelated to pemphigus vulgaris.

Pemphigus Vulgaris

Dr. Terri Rees

Pemphigus Vulgaris(BCD) (September 13, 2012)

• Females 69.0% average age 48.1 years• Males 31.0% average age 44.9 years• Combined average age 47.1 years

Dr. Terry Rees

Skin Lesions

• Bullae• Erosions• Can lead to fluid loss and electrolyte imbalance

Septicemia

Dr. Terry Rees

Oral Sites

� Mucosa 60.4%

� Gingiva 43.4 %

� Tongue 35.9%

� Palate 26.4%

� Lips 26.4%

� Mucosa only 11.3%

� Gingiva only 7.6%

� Tongue only 5.7%

Pemphigus Vulgaris Treatment� Topical corticosteroids- rare

(Endo et al J Periodontol 2005;76:154-160)

� Topical carrier trays for gingival lesions

(Endo et al J Periodontol 2005, 2007)

� Intralesional steroid injections

� Short and long term systemic corticosteroids

Preferred Topical Corticosteroid

� Clobetasol gel 0.05%

� Dispense 30 gm or 45 gm

� Pre-dry area of application with gauze, when possible

� Apply to affected areas 2-3 times daily

� One application should be at bedtime

Intralesional Corticosteroid� Kenalog 10 (triamcinolone acetonide 10 mg/ml.� How supplied: 5mg vial� Shake well before use� Apply topical anesthetic to lesion� Use 1 ml tuberculin syringe to deposit 0.1ml/cm3 into lesion intradermally or

subcutaneously� Repeat weekly for 3 weeks if needed

Systemic Corticosteroid

� Prednisone: take 30 or 40 mg/daily in single dose for one week or until medical appointment can be scheduled.

� If continued treatment is necessary, decrease dosage by 10 mg/day at weekly intervals until consumed.

� Refer to dermatologist or internist for long term therapy.

Medical Alternative Treatments

� Aziathioprine

� Dapsone

� Mycofenolate mofetil

� IV immune globulin

� Retuximab (monoclonal antibody)

� Plasmophoresis

� Others

Paraneoplastic Pemphigus

� First described by Anhalt in 1990, now more than 200 cases reported in lit.

� Most tumors are of hematological origin (non-Hodgkin lymphoma, leukemia, Castleman’s disease etc.)

� Castelman’s disease is most frequent association in children and adolescents

� Almost all have oral involvement and may be first symptom

� PP tends to be less responsive to conventional treatment

� DIF shows intraepithelial and BMZ IgG and C3 presence

� IIF on rat bladder is diagnostic

Paraneoplastic Pemphigus14 year old Hispanic female with Castleman’s Disease

Castleman’s Disease

� A benign or premaligant lymphoproliferative disease with hyalinization of vessels and/or plasma cell infiltration.

� May occur in any part of the body

� The chest, neck abdomen, and pelvis are common sites

� Treatment:

� Resection

� Systemic corticosteroids, cyclosporine, retixumab, others

Castleman’s Disease Associated with PNP� Literature Review

� 28 total patients (8-68 years of age)

� 11 females, 17 males

� All patients had painful oral stomatitis (28)

� Patients had respiratory involvement (26), death from respiratory failure (22), lichenoid skin lesions (19)

� All cases developed oral lesions first which led to diagnosis of neoplasm (Castleman’s disease)

Nikolskaia et al. British Journal of Dermatology 2003: 149, 1143-1151.

Differential Diagnosis

� Erythema Multiforme (EM)

� Pemphigoid

� Pemphigus

Pathology Report

� Lymphocytes and plasma cells

� Isolated eosinophils

� Diagnosis:

� Chronic mucositis

� Non-specific but favors EM

Direct Immunofluorescence (DIF)

� Non-specific

� Positive granular C3 at basement membrane

� Weak staining cytoid bodies (IgM, C3)

� Diagnosis:

� Non-specific but favors EM

Treatment

� Patient placed on 30 mg of prednisone daily (single dose)

� Repeat Testing:

� Biopsy for H&E and Direct Immunofluorescence

� Serum for Indirect Immunofluorescence

Direct Immunofluorescence

� Weak staining cytoid bodies

� Few necrotic keratinocytes

� Weak staining of C3 and IgG

� Trace intracellular staining in lower squamous mucosa

� Diagnosis:

� Consistent with pemphigus (Consider paraneoplastic due to Castleman’s Disease)

Indirect Immunofluorescence (IIF)

� Serum tested against antibodies:

� Anti-pemphigus antibodies 1:80� Reference range 1:10

� Anti-pemphigoid antibodies 1:10 � Reference range 1:10

� Diagnosis: Consistent with pemphigus vulgaris

Indirect Immunofluorescence (Rat Bladder)

� Blood serum samples:

� Sent to Johns Hopkins, Division of Dermatology

� IIF

� Anti-pemphigus antibody 1:320

� Reference range 1:10

� Diagnosis:

� Paraneoplastic pemphigus (PNP)

Oral Hypersensitivity ReactionsOral Hypersensitivity Reactions

Types of Allergic Reactions (BCD)(9/12)

� Lichenoid Drug 59

� Dental Restorative Materials 51

� Cinnamon/Toothpaste 50

� Erythema Multiforme 14

� Foods and others 11

Contact Stomatitis versus Contact Dermatitis

� Allergic/irritant stomatitis requires longer period of contact

� Saliva dilutes or removes sensitizers and may exert a buffer or neutralizing effect

� Mucosal vascularity may induce rapid dispersion and absorption

Contact Hypersensitivity Reactions 327 Patients (September 13, 2012)

� Female 285 (87.2%)

� Male 42 (12.8%)

� Average age

� Female 48.8 years

� Male 46.8 years

� Combined 48.4 years

Signs of Dentifrice Allergy

� Generalized or localized gingivitis

� Mucositis/glossitis

� Cheilitis

� Lip edema

� Perioral dermatitis

Dentifrices

Ingredients

Flavoring (cinnamic aldehyde)

Coloring agents

Abrasives

Soaps or detergents

Preservatives

Sensitization

Common

Rare

Rare

Rare

Common

Flavoring Agents

� Cinnamon oil

� Cinnamic aldehyde

� Menthol (also in peppermint)

� Mint/spearmint

� L-carvone

� Anethole

� Essential oils(eucalyptus oil)

� Eugenol

� Peppermint

� Wintergreen (methyl salicylate)

� Clove oil

Toothpaste Hypersensitivity

� Sensitivity to tarter control and other toothpaste usually involves the flavoring agents, especially cinnamic aldehyde

� Adverse reactions, although uncommon, should be considered in the differential diagnosis of oral or gingival edema, erythema or ulceration

� Oral biopsy and patch testing are important in confirming such reactions and the etiologic agent involved.

Allergy to Dental MetalsNickel Palladium/Platinum

( Cross reactive with nickel)

Mercury Titanium (Rare)

Gold Silver

Chromium Copper

Cobalt Berylium

Nickel Allergy

� Nickel is found in bobby pins, needles, pins, metal lipstick holders, watch backs, earring studs, stainless steel (orthodontic bands and wires), metallic dental restorative material.

� Approximately 6% of Americans are allergic to nickel.

� 10% of women are allergic.

Dental Amalgam (Mercury)

Titanium Hypersensitivity

� Titanium is readily dispersed into adjacent tissues and serum

� The material is extremely biocompatible but occasional hypersensitivity has been reported

� Effectiveness of patch testing has not been fully validated

Allergy to Non-Metallic RestorationsAllergic reactions may be more common than previously recognized.

Reactions are most often to residual methyl methacrylate monomer or its degenerative products:

Formaldehyde

Benzoyl peroxide

Debutyl phthalate

Allergy to Non-Metallic Dental Restorations (cont.)

� Some reactions are due to irritant effect rather than allergy.

� Auto-polymerizing acrylic resins release more residual chemicals and are more likely to precipitate adverse reactions.

� Typical allergic reactions include surface erythema and lichenoid changes.

Resins, Epoxy and Acrylates

� Found in:

� Dental composites� Pit and fissure sealants� Orthodontic adhesives� Glazes

� Root canal sealants� Bonding agents� Veneers� Temporary crowns

The Role of Metallic Dental Restorations in the Etiology of Mucosal and Periodontal Diseases

Patients Evaluated� Lichen planus 178

� Burning mouth 125

� Allergic stomatitis 54

� Hyperkeratosis 37

� Restoration related

gingivitis/periodontitis 44

Total patients 438

Diseases Associated with Metals Allergy

� Gingivitis/periodontitis 9

� Lichenoid reactions 5

� Allergic stomatitis 3

� Burning mouth 1

Total 18

(4.1%)

Terry Rees DDS, MSD

Baylor College of Dentistry

214-828-8135

trees@bcd.tamhsc.edu